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F0658
D

Failure to Follow Medication Administration Policy

San Diego, California Survey Completed on 08-04-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

Licensed Nurses (LNs) at the facility failed to follow established policy and procedure regarding medication administration for a resident diagnosed with hypothyroidism and acid reflux. The resident, who was alert and oriented and had decision-making capacity, reported not receiving his morning medications on time. Upon inquiry, it was discovered that one LN had prepared the medications, another LN administered them, and a third LN had already signed the Medication Administration Record (MAR) as if the medications had been given, even though the resident had not yet received them. This process was confirmed through interviews with the involved LNs and review of the resident's clinical record. The facility's policy requires that the same licensed individual who prepares the medication must administer it and document the administration in the MAR. The Director of Nursing and Administrator confirmed that this expectation was not met in this instance, as the tasks were divided among three different LNs, contrary to policy. This deviation from professional standards of practice created the potential for medication errors, as the MAR did not accurately reflect the actual administration of medications.

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